2017 EKG Workshop Advanced. Family Medicine Review Course Lou Mancano, MD, FAAFP Reading Health System Family and Community Medicine Reading, PA

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1 2017 EKG Workshop Advanced Family Medicine Review Course Lou Mancano, MD, FAAFP Reading Health System Family and Community Medicine Reading, PA

2 Part II - Objective Describe a useful approach to interpreting challenging EKGs Discuss some advanced EKG concepts through cases Demonstrate how to systematically apply the basic principles of EKG interpretation to uncover interesting and/or significant EKG findings

3 Disclosure The speaker has nothing to disclose

4 Approach to EKG Interpretation Rate Rhythm Axis Intervals (PR, QRS, QT) Chamber sizes QRST changes

5 Case 1 A 62 year old female with Type 2 diabetes mellitus presents with diaphoresis

6 Case 1: Rate Rate: is the rhythm regular or irregular? Answer: irregular How do you determine rate?

7 Rate with Regular Rhythm The rule

8 Rate with Irregular Rhythm For irregular rhythms, check the EKG s 3 second markers (15 large boxes). Count the complexes beginning with zero within a 30 large boxes (6 seconds) and multiply by 10 = avg # beats/60 sec. or estimated beats per minute large boxes (6 seconds)

9 Case 1: Rate

10 Case 1: Rhythm Rhythm is irregular but Are there p waves? Yes Are the p waves upright in lead II? Yes Are the p waves regular or irregular? Regular Is this sinus rhythm? Yes (we ll get back to this) Next determine the QRS axis

11 QRS Axis

12 Case 1: QRS Axis Let s determine the QRS Axis. Choose the limb lead where the QRS complex is closest to isoelectric and draw a yellow line. Draw a red line perpendicular to this line. This is on avl. If the QRS on avl is upright (positive), then axis = -30. If the QRS would have been downward (negative) then axis =

13 QRS Axis Our patient has a left axis deviation. What are causes of LAD?

14 Case 1 Negative 30 to negative 90 degrees Mechanical shifts (elevated diaphragm) LBBB Left Anterior Fascicular Block or LAHB WPW syndrome (sometimes) Inferior wall MI Sometimes LVH

15 Case 1: Intervals QRS duration: How many boxes is the QRS complex? It s just under 3 boxes or 0.11 seconds.

16 Case 1: Intervals Normal QRS complex duration is msec (1.5 to 2.5 small boxes) This patient s is 110 msec Intermediate QRS is > 100 to < 120 msec seen with junctional beats, high ectopic ventricular beats, hemiblocks, electrolyte abnormalities (i.e. severe hyperkalemia) and with some medications (some antiarrhythmic agents) Ventricular beats or Bundle Branch Blocks > 120 msec. This EKG rhythm is not considered wide complex, so while the QRS isn t normal, it s still categorized as a narrow complex (atrial or junctional) rhythm We have no labs or other history to help us on this patient

17 Case 1 Intervals What is her QTc interval? The normal QTc interval is considered to be from 360 msec to 450 msec in males and to 460 msec in females To calculate the QTc, first measure the QT interval. In this case the average QT is ~0.39 seconds. Then measure the average R-R interval. This one is 0.86 sec. Plug them into: and this QTc is normal = 0.42 sec

18 Intervals PR intervals: normal is 0.12 sec to 0.20 sec (3 to 5 small boxes) Our patient s PR intervals vary. PR interval variation can be seen with different atrial foci or due to AV nodal disease. (examples include PACs, WAP, MAT, 2 nd Degree AV Block) Our patient is in sinus rhythm (the same p wave morphology) with a 2 nd Degree AV Block, Type 1 or Wenckebach

19 Atrioventricular Blocks 2 nd Degree AV Block Type 1 (Wenckebach) In classic Wenkebach, the PR interval gets longer until a nonconducted P wave occurs. The RR interval of the pause is shorter than the sum of the 2 preceding RR intervals, and the RR interval after the pause is longer than the RR interval before the pause. The block is located in the AV node.

20 Case 1 summary EKG interpretation at this point Rate = 70 and irregular Rhythm = atrial is regular at < 100 bpm, narrow complex with positive p wave in lead II, c/w sinus rhythm With Wenckebach QRS axis = -30 or left axis deviation Intervals: PR varies due to Wenckebach QRS duration is 0.11 sec (intermediate) QTc interval = 0.42 sec (normal) Chamber sizes (will be addressed in another case); they re normal here

21 QRST Changes/Abnormalities Are there any ST elevations? Leads II, III, avf How many mm.?

22 Acute Myocardial Infarction ECG diagnosis requires at least 1 mm (0.1 mv) of new ST segment elevation in corresponding anatomical limb leads, V4, V5 or V6 At least 2 mm elevation in males (1.5 mm in females) at the V2 and V3 J- point These elevations must be anatomically contiguous. I, avl, V5, V6 = lateral wall V1, V2, and sometimes V3 = septal or anteroseptal wall V3, V4 = apical or anteroapical wall II, III, avf = inferior wall True posterior MI pattern with ST depression in V1, V2, and sometimes V3 New LBBB in suspicious setting

23 Our patient seems to be having an acute inferior wall infarct. Is that all?

24 QRST Changes/Abnormalities Are there any ST depressions? Leads 1, avl and V2-3; maybe upsloping in V1

25 Reciprocal Changes The inferior wall infarct (II, III, avf) does not have true reciprocal leads, but If the infarct extends posteriorly (inferior-posterior infarct), ST depressions can occur in the anteroseptal (V1, V2 and sometimes V3) and high lateral leads (I, avl) This occurs in our patient which helps solidify the diagnosis of an acute inferior-posterior infarct V1 V2

26 Reciprocal Changes Acute anteroseptal infarctions (V1, V2, V3) may show reciprocal lateral changes in V5, V6, I, and/or avl. A left lateral wall infarct (V5, V6, I, avl) may show reciprocal changes in avr, and sometimes V1 and V2 (depending on lead placement and how lateral the infarction is). A right sided infarct (rv4, avr) may show reciprocal changes to the left lateral leads (V5, V6, I, avl). V1 V2

27 Case 1 EKG Final Interpretation Atrial rhythm is probably sinus at a rate of 90 to 100 bpm with an irregular average ventricular rate of 70 bpm Irregular ventricular rate is due to 2 nd Degree AV block Type 1 or Wenckebach Left axis deviation (-30 degrees) QRS duration is 0.11 sec (intermediate) QTc interval = 0.42 sec (normal) Chamber sizes are normal The 2 nd degree Type 1 AV block (Wenckebach) and the left axis deviation are due to an acute inferior-posterior wall infarction with reciprocal changes seen in leads I, avl, (V1) V2 and V3

28 Case 2 59 year old male smoker with hypertension on lisinopril with substernal chest pain and mild shortness of breath for the past 30 minutes

29 Case 2: Rate Rate: is the rhythm regular or irregular? Answer: irregular How do you determine rate for an irregular rhythm? Rate = 70 and irregular

30 Case 2: Rhythm Rhythm is irregular Is it narrow or wide complex? Narrow Name some narrow complex irregular atrial rhythms: Wandering atrial pacemaker Sinus arrhythmia Multifocal atrial tachycardia Atrial flutter with variable block Sinus rhythm with PACs or PJBs Atrial fibrillation Are there p waves? No Atrial fibrillation (coarse and fine) Coarse atrial fibrillation

31 Case 2: QRS Axis QRS Axis: Choose the limb lead where the QRS complex is closest to isoelectric and draw a yellow line. QRS Axis: Draw a red line perpendicular to this line. This is on lead I. If the QRS on I is upright (positive), then axis = 0 which is normal. If the QRS would have been downward (negative) then axis = +180.

32 Case 2: Intervals PR interval is? Cannot calculate because there are no true p waves QRS duration is 100 msec (is upper limit of normal but normal) QTc interval = 0.41 sec

33 Case 2: Chambers Cannot determine LAE or RAE because we need to measure p waves (and there are no p waves in atrial fibrillation) Are any ventricles enlarged? Criteria for LVH

34 11 mm 16 mm 23 mm 18 mm Sokolow-Lyon Indices: S wave in V1 + R wave in V5 or in V6 = 35 mm or more OR R wave in avl > 11 mm Cornell Voltage Criteria: S wave in V3 + R wave in avl > 28 mm in males and > 20 mm in females Supporting evidence includes left axis deviation and widened QRS/T angle usually seen in leads V5 and V6 (called LV strain pattern)

35 Case 2 summary EKG interpretation at this point Rate = 70 and irregular Rhythm = coarse atrial fibrillation QRS axis = 0 degrees (normal) PR interval cannot calculate QRS duration is 0.10 sec (normal) QTc interval = 0.41 sec (normal) Chamber sizes: LVH

36 Let s look at ST segments and T waves ST depressions and T wave inversions in leads I and avl Is this finding old or new? New LVH-related depolarization variant is usually not seen in leads I and AVL. These could represent lateral ischemia or reciprocal changes. Biphasic T waves seen in leads V2, V3 and V4 are Wellen s waves seen with a tight proximal LAD stenosis

37 Wellens syndrome or LAD coronary T-wave syndrome. Criteria include: Characteristic T-wave changes History of anginal chest pain Normal or minimally elevated cardiac enzyme levels ECG without Q waves or significant ST elevation; normal precordial R-wave progression. The common form shows deep T wave inversion in precordial leads. The ST segment will be straight or concave, and pass into a deep negative T wave at an angle of degrees. The T wave is symmetric. These changes generally occur in leads V 1 -V 4 but may occasionally involve V 5 and V 6.

38 The less common variant of Wellens syndrome (24% of patients) consists of biphasic T waves, most commonly in leads V 2 and V 3, but also can include V 1- V 5 /V 6.

39 Case 2 summary EKG interpretation Rate = 70 and irregular Rhythm = coarse atrial fibrillation QRS axis = 0 degrees (normal) PR interval cannot calculate QRS duration is 0.10 sec (normal) QTc interval = 0.41 sec (normal) Chamber sizes: LVH Acute anteroseptal/apical infarction c/w Wellen s Syndrome

40 Case 3: 51 year old complains of palpitations. What is the rhythm? Are there P waves?

41 Case 3: AV Nodal Re-entrant Tachycardia No definite p waves seen before the QRS, rate ~ 150 to 200 and very regular. May see retrograde p waves (seen as pseudo-terminal S waves in leads II & avf, and pseudo-r in V1)

42 Case 4: 42 year old male with sharp substernal chest pain What is your diagnosis and why? Are the ST segment and T wave abnormalities distributed in anatomical leads?

43 Case 4: Acute Pericarditis

44 Case 5: This patient is asymptomatic and had a Welcome to Medicare exam. Comment on the conduction system abnormalities?

45 Right Bundle Branch Block 120 ms Complete RBBB has a widened QRS > 0.12 sec Terminal forces (2 nd half of QRS) are oriented rightward and anteriorly toward V1 and V2 (positive deflections) because the RV is depolarized after the LV The terminal negative deflection in V6 (wide S wave) represents RV depolarization

46 Left Anterior Fascicular Block When isolated LAFB, QRS duration < 0.12 sec Left Axis Deviation (usually < - 35 degrees) Small Q waves in leads I and avl; S > R waves in leads II, III, and avf Sometimes a deep S wave in V6

47 Case 5: Bifascicular Block with Right Bundle Branch Block & Left Anterior Fascicular Block >0.12 sec QRS Axis < -35

48 Case 6: 68 y.o. w/ dyspnea. Let s interpret the EKG Rate 60 & irregular Rhythm? QRS 110 ms QTc 430 ms PR? Axis -70 Left Axis Deviation etiologies: Mechanical shift (elevated diaphragm) LBBB; LAFB; sometimes WPW; Inferior wall MI; sometimes LVH Atrial flutter with variable block Inferior Q waves & poor R wave progression, c/w inferior and anterior infarcts, age undetermined Lateral T wave inversions

49 Case 6: Atrial Flutter with Variable AV Block

50 Case 7: 59 y.o. smoker w/ worsening cough and wheeze. Let s interpret this EKG Rate 140 & irregular Rhythm? (we ll review on next slide) Axis +88 QRS 93 ms QTc 450 ms PR? Poor R wave progression V1 4 c/w anteroseptal infarct, age undetermined Lateral T wave inversions

51 Case 7: Multifocal Atrial Tachycardia

52 Case 8: 41 y.o. has been intermittently feeling very lightheaded. Does anything appear unusual on this EKG? Rate = 64 bpm Rhythm = 76 Axis = + 58 degrees PR = 0.18 sec QRS = 0.11 sec QTc = 0.42 Segments? Bundles? QRS? V1-2-3 RBBB pattern cove pattern often with a 1 st degree AVB (not in this case) Brugada Syndrome Type 1

53 Case 8: Brugada Syndrome recognized in 1988 and described in 1992 is a genetic sodium channel defect that leads to V fib. Worsened by Class 1C antiarrhythmics (i.e., flecanide) and vagal maneuvers ECG abnormality must be associated with one clinical criteria to make the diagnosis: Documented ventricular fibrillation or polymorphic ventricular tachycardia Family history of sudden cardiac death at <45 years old Coved-type ECGs in family members Inducible VT with programmed electrical stimulation Syncope or Nocturnal agonal respirations

54 Brugada Syndrome Type 2

55 Case 9: 18 y.o running track returns to the gym and he and a friend decide to play with a trainer s EKG machine. Ventricular rate = 112 bpm Sinus tachycardia PR interval = 178 ms QRS duration = 112 ms QT/QTc = 328/452 ms Axis = + 68 degrees Incomplete RBBB Rsr in V1 QRS duration msec T wave inversions in leads V1-2-3 can be normal in Incomplete RBBB Should this student be disqualified from running track?

56 Case 9: Seattle Criteria for Normal EKG Findings in Athletes Sinus bradycardia (>30 bpm) Sinus arrhythmia Ectopic atrial rhythm Junctional escape rhythm Mobitz Type I (Wenckebach) 2 nd degree AV block Incomplete RBBB Isolated QRS voltage criteria for LVH (no LAE, LAD, ST depression, T wave inversions, or pathological Q waves) Early repolarization (J point elevation) Convex ( domed ) ST segment elevation w/ T wave inversion leads V1-4 in AA athletes

57 Case 10: This patient is new to your practice and sends ahead his records which include this EKG that s not interpreted. S > R wave in I & AVL No RVH Small Q in II, III, AVF Axis ~ +120 QRS <0.12 Ventricular rate = 112 bpm Rhythm = Sinus tachycardia PR interval = 190 ms QRS duration = 101 ms QT/QTc = 412/443 ms Axis = degrees Right Axis Deviation etiologies: Mechanical shifts (emphysema) RBBB RVH LPFB WPW syndrome (some) Dextrocardia Lateral wall MI Acute right heart strain (large PE) Left Posterior Fascicular Block Poor R wave progression V2 V4 c/w old anterior infarct

58 Case 11: 51 year old female feels palpitations and lightheadedness. Rate = 180 bpm QRS = 0.15 sec Rhythm =? Is this rhythm an aberrantly conducted SVT or ventricular tachycardia? Leads V2-3 have rsr pattern which favors SVT with aberrancy (RSr would favor V-tach) Positive or negative concordance throughout chest leads (i.e. leads V1-6 show entirely positive R complexes or entirely negative QS complexes), with no RS complexes seen, favors V-tach; lack of concordance (RS complexes) favors SVT w/ aberrancy

59 Case 11: Wide Complex Tachycardia EKG differentiation of VT from SVT with aberrancy is not always possible, some features favoring VT include: AV dissociation (identify P and QRS complexes at different rates) Capture beats - the SA node transiently captures the ventricles, in the midst of AV dissociation, to produce a QRS complex of normal duration

60 Fusion beats - when a sinus and ventricular beat coincide to produce a hybrid complex Brugada s sign - distance from the onset of the QRS complex to the nadir of the S wave is > 100ms Josephson s sign - notching near the nadir of the S wave

61 RSr complexes with a taller left rabbit ear strongly favor of VT In contrast to RBBB and SVT with aberrancy, where the right rabbit ear is taller (rsr )

62 Is this V-tach or SVT with aberrancy? Brugada criteria: Is there absence of RS complex in all V1-V6 leads? If Yes, V-tach. If No, is an RS complex > 100 ms in any? If Yes, V-tach. RSr (seen in V4) would favor V-tach Josephson s sign seen in avl

63 Case 12: 53 y.o. male with hyperlipidemia, hypertension and smoking presents with left jaw pain. Is he having an infarct? If so, where? Anteroseptal MI with lateral lead reciprocal changes

64 Case 13: 19 year old with intermittent dizziness and palpitations Rate: 62 Rhythm: Sinus with PAC Axis: -45 (mechanical shift, LBBB, LAFB, sometimes WPW, inferior wall MI, sometimes LVH) PR: 110 msec QRS: 106 msec QTc: 395 msec Delta waves, intraventricular conduction delay

65 Case 13: Wolff-Parkinson-White Syndrome An absent or difficult to see negative delta wave in V1, and S > R in V1 indicates a right sided insertion of accessory pathway; A positive delta wave in V1 and R > S in V1 indicates left sided insertion

66 Case 14: What is the rhythm? Sinus rhythm with third degree heart block

67 Case 15: Which two chambers are enlarged? Right Ventricle and Right Atrium Negative QRS in Lead 1 Positive QRS in Lead V1 Lead II p > 2.5 mm tall May see RV strain in V1-2-3 Axis = +210 degrees May have deep S wave in V5 and V6 Tall R Wave in V1 = Mechanical shifts; Posterior MI; WPW syndrome; Dextrocardia; Right Ventricular Hypertrophy; Right Bundle Branch Block; Lateral Wall MI Acute Right Heart Strain; Children under age 2

68 References Stein, E. Rapid Analysis of Electrocardiograms. Lippincott, Williams & Wilkins Marriott, H. Practical Electrocardiography. Williams & Wilkins Accessed January Documents/EKG.pdf

69 Thank You

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